Skincare Routine Assessment Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Ethnicity
Allergies and Sensitivities
Do you have any known allergies or sensitivities to skincare products or medications?
Lifestyle and Environment: Where do you live? (e.g., urban, rural, humid, dry climate) Do you spend significant time outdoors or in environments that may affect skin? What is your current level of physical activity or exposure to sweat?
How do you describe your skin?
Super Oily
Oily
Combination
Dry
Sensitive
What type of acne are you experiencing? (e.g., blackheads, whiteheads, cystic, nodular)
blackheads
whiteheads
Cystic, painful, inflamed acne breakouts
Are there specific areas where acne is most prominent?
Forehead
Inner cheeks
Outer cheeks
Chin
Jawline
Neck
Nose
Chest
Back
What skincare products have you been using? Please list all you use over-the-counter and prescription?
How often do you use them? Morning and night? Once a day? Once a week?
Any products caused irritation or adverse reactions? If so, please let us know what it was. Anything that worked well?
Are there any identified triggers for your acne that you are aware of? (e.g., stress, diet, hormonal changes)
Women Only: Do you notice a connection between your menstrual cycle and acne flare-ups? If so, please explain:
Do you wear makeups? If so, what do you use?
No need to write your eye makeups. Just foundation, concealer, blush, and blonzer.
What hair products, and toothpaste do you use? Are they acne-safe?
List the name of the products so that we can check the ingredients.
Are you taking any medications or supplements right now?
List all the medications and supplements you are taking currently.
Do you have any concerns or questions about your skin or routine?
Image #1: Please upload three images. (Face Acne: Front, Right & Left. Back: Shoulder, Whole Back & Lower Back. )
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Choose a file
Please take a picture of your whole face. Do not zoom into the problem area.
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Image #2
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Choose a file
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Image #3
Browse Files
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Choose a file
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Thank you for submitting this form.
We will be emailing you with your personalized skincare routine recommendation and a coupon code within 72 business hours. If you have any questions in the meantime, please don’t hesitate to reach out, we’re here to help!
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